Articular Status of a Child with Arthritic Symptoms

Essentials

• Arthritis in a child presents as joint swelling, limitation of motion, or both, and it is usually associated with tenderness on movement and/or increased warmth of the joint.
• In aseptic arthritis, pain is rarely a prominent symptom, whereas stiffness after rest is a typical sign.
• A bacterial arthritis is usually associated with short-lived pain in a single joint as well as general symptoms like fever.
• When examining the child, the most important thing is to observe how the child moves, to assess how the child uses his/her limbs and to examine the symmetry of the joints.

Symptoms of arthritis in a young child

• Joint pain or tenderness is a common symptom in acute arthritis.
• In prolonged conditions, the symptoms are usually associated with changes in the use of the limbs; limping or avoiding the use of the limb is most typical.
• The parent's description of the symptoms often discloses the localization; the most commonly inflamed joints are the knee, the hip and the ankle.
• If the child
  • does not get up from the bed but wants to be carried: one of the large joints of the lower extremities
  • keeps one knee in flexion: knee, hip
  • when crawling supports on the knuckles of clenched fists instead of palms: (wrist
  • does not turn the head when looking at the side but rotates the upper body: cervical spine
  • cannot handle the spoon and cup in the morning: MCP and PIP joints of the fingers.

Examination of the joints

1. Observe the symmetry of movement when the child moves around, walks and runs. A limp in a small child is an important clue as regards pain or stiffness.
   • Slight clumsiness when running is dependent on the age and the developmental phase of the child but may also have inflammatory or neurological background.
2. Compare the joints and recognize swellings (usually asymmetrical; picture 1). Note asymmetry in the motion ranges of the joints and possible pain on movement (muscle guarding, resistance) in extreme joint positions even if the ranges of motion were normal.
   • Plantar and dorsal flexion of the ankle, lateral movements of the heel
   • Maximal flexion and extension of the knees while the child lies supine on the examination table or on the lap of the parent. Normally the heels touch the buttocks without difficulty and there is at least few degrees of symmetrical hyperextension in the knees.
   • Rotation of the hip joints while the child lies supine, with the hips and knees flexed 90° (picture 2). Almost all diseases of the hip first affect internal rotation.
   • Symmetrical full extension and flexion of the elbows
   • Maximal extension of the wrists (picture 3): symmetrical and at least 80°
   • Flexion of fingers II-V to the distal palmar fold. Normally the fingertips can easily touch the palm (picture 4).
   • Range and symmetry of the movements of the cervical spine: rotation (normally 90° in both directions) and backwards extension
   • Palpation of the temporomandibular joints and examination of the opening of the mouth (should be straight and wide)
3. Provoke pain. At the sacroiliac joint this is performed by pressing the pelvic girdle firmly from both sides (picture 5). Pain originating from the sacroiliac joints radiates to the buttocks. Absence of pain does not rule out sacroilitis. Pain at the MTP joints of the foot and MCP joints of the hands can be provoked by pressing the foot or hand from the sides at the joints.